Stevenson, J.E., Israelsson, J., Petersson, G. et al. (1 more author) (2018) Factors influencing the quality of vital signs data in electronic health records: a qualitative study. Journal of Clinical Nursing, 27 (5-6). pp. 1276-1286. ISSN 0962-1067
Abstract
AIMS AND OBJECTIVES:
The purpose of this study was to investigate reasons for inadequate documentation of vital signs in an electronic health record.
BACKGROUND:
Monitoring vital signs is crucial to detecting and responding to patient deterioration. The ways in which vital signs are documented in electronic health records have received limited attention in the research literature. A previous study revealed that vital signs in an electronic health record were incomplete and inconsistent. DESIGN: Qualitative study.
METHODS:
Qualitative study. Data were collected by observing (68 hours) and interviewing nurses (n=11) and doctors (n=3), and analysed by thematic analysis to examine processes for measuring, documenting and retrieving vital signs in four clinical settings in a 353-bed hospital.
RESULTS:
We identified two central reasons for inadequate vital sign documentation. First, there was an absence of firm guidelines for observing patients' vital signs, resulting in inconsistencies in the ways vital signs were recorded. Second, there was a lack of adequate facilities in the electronic health record for recording vital signs. This led to poor presentation of vital signs in the electronic health record and to staff creating paper 'workarounds'.
CONCLUSIONS:
This study demonstrated inadequate routines and poor facilities for vital sign documentation in an electronic health record, and makes an important contribution to knowledge by identifying problems and barriers that may occur. Further, it has demonstrated the need for improved facilities for electronic documentation of vital signs.
RELEVANCE TO CLINICAL PRACTICE:
patient safety may have been compromised because of poor presentation of vital signs. Thus, our results emphasised the need for standardised routines for monitoring patients. In addition, designers should consult the clinical end-users in order to optimise facilities for electronic documentation of vital signs. This could have a positive impact on clinical practice and thus improve patient safety.
Metadata
Item Type: | Article |
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Authors/Creators: |
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Copyright, Publisher and Additional Information: | © 2017 John Wiley & Sons Ltd. This is an author-produced version of a paper subsequently published in Journal of CLinical Nursing. Uploaded in accordance with the publisher's self-archiving policy. |
Keywords: | electronic health records; patient safety; qualitative study; vital signs |
Dates: |
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Institution: | The University of Sheffield |
Academic Units: | The University of Sheffield > Faculty of Social Sciences (Sheffield) > Information School (Sheffield) |
Depositing User: | Symplectic Sheffield |
Date Deposited: | 13 Dec 2017 10:36 |
Last Modified: | 15 Dec 2023 10:29 |
Status: | Published |
Publisher: | Wiley |
Refereed: | Yes |
Identification Number: | 10.1111/jocn.14174 |
Related URLs: | |
Open Archives Initiative ID (OAI ID): | oai:eprints.whiterose.ac.uk:124919 |